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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Gas Station A 00 j >y � q siq 0V�� 91D V(0 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> VIXxo <br /> FACILITY NAME <br /> TEleven #17334 <br /> SITE ADDRESS <br /> 4501 N . Pershing Ave. Stockton 95207 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7000 E. Shea Blvd. Ste H1970 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Scottsdale AZ 85254 <br /> PHONE #1 ExT, APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK if BILLING ADDRES <br /> Veronica Freitas S <br /> BUSINESS NAME PHONE # ExT, <br /> Walton Engineering, Inc. 916 373-1166 <br /> HOME Or MAILING ADDRESS FAX # <br /> P .O . Box 1025 ( ) <br /> CITY West Sacramento STATE CA Zip 95691 <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . <br /> APPLICANT'S SIGNATURE: ; DATE : 11 /4/2022 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® Contractor <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS prpj�e o me or <br /> my representative . �'1 M <br /> TYPE OF SERVICE REQUESTED : 1 ,1 ,f r / el t;VV l VF <br /> COMMENTS: IVUV Z)OI�L �� -Q . N 'l�il� �/2 �.� S,qN Joq 6 ?OZ? <br /> NEA Ty p F��ANT <br /> MENT <br /> ACCEPTED BY : EMPLOYEE # : DATE: l 2Z <br /> ASSIGNED TO : 0ne � EMPLOYEE # : DATE: <br /> Date Service Completed (if already completed) : 7 Z� SERVICE CODE : f� (i �� P IE 2 50 Y' <br /> Fee Amount : , Amount Pal Payment Pay/menat Date <br /> Payment Type ( Invoice # Check # � � �� d Received By : <br /> �ctllllJ2� D � � a P-6IYYI/ 1(w- Pe,,t2d� <br /> EHD 48-02-025 p c� SR FORM (Golden Rod) <br /> 07/17/08 A; � /J O Z 72 o7 <br />